Mandated Treatment: Lessons From Research With Drinking and Driving Offenders.

Institutions, such as the courts, have been mandating referrals to alcoholism treatment with increasing frequency in recent decades. Because of this trend, defining the differences between mandated and voluntary treatment goals and effectiveness has become more important.

During the past three decades, both public and private alcoholism treatment systems have been altered profoundly by the increased use of mandated referrals, which include court mandates requiring treatment, referrals from the workplace (where there is actually a range of coer cion levels from mild suggestions to "employee's job is in jeopardy" referrals), and referrals from the criminal justice system (Weisner 1990).Referrals from the latter typically result from charges of public drunkenness; alcoholspecific offenses, such as driving under the influ ence (DUI); or other crimes (such as domestic violence) in which alcohol is suspected to have been a contributing factor.Some of these mandatory referral sources have grown enough that by the mid1980's, on the average, 35 percent of all treatment facilities in the United States offered an employee assistance program (EAP) for workplace referrals and 39 percent offered services for courtreferred drinking and driving offenders (Weisner 1990).In some States, programs for court referred drinking drivers have tended to dominate alcoholism treatment services (Weisner 1990).
The increasing frequency of institution ally mandated referrals has generated important questions for treatment of alco hol problems.How effective are alcoholism treatment programs for people who are mandated into treatment?What goals are appropriate for these people?For example, should the goal of treatment for DUI of fenders2 solely be the prevention of future drinking and driving events, or should the goal be broadened to include reduction of the offenders' alcohol problems?
Many issues of policy and ethics also surround the use of mandated treatment, emanating especially from the courts (Weisner 1990).The concerns include the civil rights of people involuntarily committed to alcoholism treatment and the fairness of requiring people with more serious alcohol problems to attend more intensive (and thus more timeconsuming, disruptive, and expensive) treatment than that required for people with less severe alcohol problems who have committed the same offense (Weisner 1990).
Thus, the subject of mandated treat ment encompasses a diverse set of issues, and available research does not address all of them equally.In exploring these questions, therefore, this article will focus on DUI offenders, a population for which a large base of research is available.

DUI OFFENDER TREATMENT REFERRALS
More is known about DUI offenders who are referred to treatment than about other mandated referral populations for several reasons: (1) DUI offenders represent such a large proportion of mandated referrals from the criminal justice system (e.g., as early as the mid1980's almost 900,000 DUI offenders were estimated to be en rolled in public programs, and the num bers have risen steadily during the intervening years [Weisner 1990]); (2) many DUI offender rehabilitation pro grams occur in public treatment settings, and evaluations of services often are required in such settings; and (3) DUI is a highly visible issue that has been subject to intense public concern by such organi zations as Mothers Against Drunk Driving.In contrast, less is known about the characteristics of other mandated referrals, such as those from the work place (Weisner 1990), possibly because such programs often occur in privately funded treatment settings that are not subject to the same level of rigorous scrutiny as those in more public settings.

Mechanisms of Mandated Referral
Within the criminal justice system, the mechanisms of referral, as well as the incentives or penalties for treatment attendance, vary broadly.Diversion from the criminal justice system to treatment can occur prior to an actual arrest or at various points in the adjudication process; in some cases, a charge (e.g., DUI) might be reduced or even avoided completely if the offender attends or completes a man dated treatment program (WellsParker and Cosby 1988).Penalties also can be reduced in exchange for treatment partici pation.For example, for DUI offenders referred to treatment, court mandates could include a reduction jail time, a period of license suspension, or a fine.Additionally, some courtmandated pro grams are structured to reduce offenders' denial of alcohol problems and to encour age and assist offenders in seeking more extensive treatment on their own.How ever, it is not known how frequently offenders elect additional treatment after completing such mandated programs.

CHARACTERISTICS OF THE DUI OFFENDER POPULATION
Studies have examined whether popula tions of institutionally mandated referrals differ in their characteristics from other populations seen in alcoholism treatment or from the general population in the United States.Among observable demo graphic differences in these populations are that males, minorities, and younger people are overrepresented in court referred populations, such as DUI offend ers (for a review, see Weisner 1990).These patterns reflect overrepresentation of the same groups in the criminal justice system.Less is known about referrals from the workplace, although there is some evidence that the workplacereferred popu lation is younger and more functional in society (e.g., by virtue of being em ployed) than are populations from other referral sources (Weisner 1990).
The "typical" DUI offender referred to treatment has been the young (under age 30) white male; however, the population of DUI offenders is increasingly diverse, with a growing proportion being women and minorities-groups that have unique problems and needs that must be taken into account when designing effective treatment (discussed below) (Wells Parker et al. 1990).

Alcohol Problems Among DUI Offenders
The DUI offender population shows considerable diversity with regard to degree, or level, and type of alcohol problems.However, the estimated per centage of DUI offenders referred to treatment who actually have serious problems with alcohol varies across re search studies (Miller and Windle 1990), because these studies differ in their defi nitions of problem severity, their instru ments of measurement, and the populations they examine.For example, classifying the severity of alcohol problems among DUI offender groups ranges from simply determining the number of prior DUI offenses drivers have accumulated (more offenses presumably indicate more severe problems) to making complex diagnoses based on multiple clinical indicators of a range of symptoms.One study, which used criteria from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Third Edition, estimated that approximately onehalf of DUI offenders referred to treatment could be diagnosed as meeting the criteria for alcohol abuse and about onefifth could be classified as alcohol dependent (Miller and Windle 1990).The range of types and levels of alcohol prob lems among DUI offenders generally appears broader than that seen among offenders in other clinical alcoholism treatment populations.DUI offenders referred to treatment have intermediate levels of alcohol problems, falling be tween the levels for the general popula tion and other (nonDUI offender) populations seen in alcoholism treatment (Donovan et al. 1983;Weisner 1990).

Problems Unrelated to Alcohol
Increasingly, evidence suggests that detected DUI offenders have a range of problems, in addition to alcohol problems, that might cause them to be safety risks (Donovan et al. 1983).For example, many arrested drinking drivers show aggressive and dangerous driving tenden cies similar to those of drivers who are arrested for nonalcoholrelated traffic offenses and who are involved in many crashes without consuming alcohol (Wilson 1992).Thus, many DUI offend ers referred to treatment are likely not only to have alcohol problems but also to have driving problems and difficulty in controlling aggressive and antisocial impulses.Indeed, a constellation of prob lem behaviors (including alcohol or other drug abuse, drinking and driving, and highrisk driving) may be related to cer tain personality characteristics as well as to social environments that tend to foster a broad range of problem behaviors.The relationship between personality and behavior frequently is used to explain the drinking and driving behavior of adoles cents and young adults (Donovan 1993).
Other DUI offenders may be respond ing to stressful situations and depression by both drinking heavily and by driving after drinking (Miller and Windle 1990).Drinking drivers increasingly are recog nized as a diverse group with a variety of emotional and psychiatric problems.An important research challenge is the identi fication of reliable and valid classifica tion schemes that could identify the various types of drinking drivers seen in treatment as well as the development of optimal treatment strategies for each type of client (WellsParker et al. 1990;Dono van et al. 1983).

TREATMENT GOALS AND METHODS FOR DUI OFFENDERS
What types of treatment are now given to DUI offenders, and how effective are they?In attempts to answer these ques tions, a statistical technique called meta analysis was used to review the literature evaluating the effectiveness of treatment of DUI offenders (WellsParker et al. in pressa).This sensitive technique permits the detection of similar patterns of results in large numbers of evaluation studies on a single topic even when the results of those studies do not show obvious acrossstudy consistencies.Conclusions from the metaanalysis were based on studies determined to have used adequate scientific methodology (WellsParker et al. in pressa).

Goals
The goal of DUI offender rehabilitation is oriented most frequently toward separat ing drinking from driving and reducing future drinking and driving behavior.These programs less frequently have been oriented toward abstinence, and programs with controlleddrinking goals usually have been tied to specific situations likely to involve driving rather than involving a spectrum of drinking situations.

Methods of Treatment
The relative emphasis on reducing drink ing and driving events distinguishes many alcoholism rehabilitation services for DUI offenders from services directed toward other alcoholabusing populations.Like wise, the type and intensity of programs for DUI offenders may not reflect treat ments typically seen for those referred from other sources.For example, many programs for DUI offenders that have been evaluated for their effectiveness (WellsParker et al. in pressa) provided education about alcohol's effect on driv ing and on the body; about the DUI law; and, in some cases, about defining and identifying alcohol problems (i.e., they were educational modalities).Psycho therapy or counseling was a principal component of approximately onethird of the evaluated treatments.
On the other hand, some forms of treatment, such as community reinforce ment, which is a broadspectrum, commu nitybased intervention that is effective in more general alcoholism treatment set tings (Miller and Hester 1986; for a de scription of this and other types of behaviorally based treatments, see the article by Kadden, pp.279-286), have never been evaluated for DUI offenders.Other common alcoholism treatments, such as traditional inpatient programs, family therapy, selfhelp manuals, and specific behaviorally based regimens (e.g., relapse prevention or selfcontrol training), were each featured as signifi cant elements in fewer than 3 percent of evaluated DUI offender programs consid ered in the metaanalysis; medication that deters drinking (e.g., Antabuse ® ) and Alcoholics Anonymous (AA) programs were included in fewer than 15 percent of the programs studied (WellsParker et al. in pressa).

TREATMENT EFFECTIVENESS
In the metaanalysis of studies of DUI offenders, treatment effectiveness first was examined across all types of offend ers and across all types of treatments that have been evaluated.Treatment had a consistently small but positive effect, as compared with no treatment, punishment (e.g., fines or jail), or licensing sanctions (e.g., suspension), in reducing the rate of repeated DUI offenses and involvement in alcoholrelated crashes.Treated offenders repeated their offenses, on the average, 8 to 9 percent less often than did untreated offenders (WellsParker et al. in pressa).
The available evaluation literature on DUI offender rehabilitation and treatment contained many limitations, making it impossible to evaluate the effects of DUI offender treatment programs on other outcomes, such as the level of alcohol consumption or the level of family stress related to alcohol abuse.However, one longterm study found that DUI offenders who attended treatment had longterm mortality rates about 30 percent lower than did those who did not attend treat ment (Mann et al. 1994).The finding suggests that some broader treatment outcome effectiveness may exist that can be determined through future research.
As stated previously, literature re viewed in the metaanalysis has shown consistently that rehabilitation is more effective than sanctions such as license revocation for alcoholrelated driving outcomes, including DUI recidivism or crashes involving alcohol (WellsParker et al. in pressa).Other studies, however, have examined effects of DUI offender programs on overall traffic safety im provement (e.g., a reduction in the number of crashes and all types of traffic citations, regardless of alcohol involvement) be cause this sometimes is an expected out come of DUI offender programs.When considering these studies, it is important to realize that approximately onehalf of all fatal crashes have been estimated not to involve drinking drivers, and police reported rates of alcohol involvement in crashes causing only property damage have been as low as 5 percent (U.S.Department of Transportation, National Highway Traffic Safety Administration, National Center for Statistics and Analysis 1994).DUI offender rehabilitation has not been found effective in providing traffic safety benefits beyond the reduction of DUI offenses and alcoholrelated crashes.In fact, when nonalcoholrelated traffic events by DUI offenders are examined, rehabilitation has tended to have a nega tive effect because it is associated with an increase in nonalcoholrelated traffic events for DUI offenders (WellsParker et al. in pressa).This may be because reha bilitation programs often have been substi tuted for suspension of the driver's license (i.e., if offenders attended rehabilitation, they did not lose driving privileges).If offenders in treatment can drive legally, they are likely to drive more frequently than offenders who do have their licenses suspended and thus are more likely to be involved in crashes (WellsParker and Crosby 1988). 3The more effective option may be DUI offender rehabilitation com bined with some loss of driving privileges (McKnight and Voas 1991).

Comparison of Treatment Types
Because educational modalities (i.e., 53 percent of the modalities evaluated in the metaanalysis) serve as the dominant form of treatment for DUI offenders, it is diffi cult to determine whether some other treat ments may be more effective in treating these offenders.

Treatments With Multiple Components.
Some research has demonstrated the efficacy of combinations of treatments.Within the metaanalysis, evaluation studies showed that treatments in which several forms of rehabilitation were combined, or multimodal treatmentsespecially those that included education; psychotherapy or counseling; and fol lowup, such as contact probation (face toface meetings with a counselor as opposed to being tracked through records) or aftercare given by providers of alco holism treatment-were more effective by at least 10 percent in reducing DUI offender recidivism than was any one of these methods alone (WellsParker et al. in pressa).The reason for this effective ness was unclear.Although some multi modal treatment involved more time and total treatment hours, intensity could not be shown to account for the differences in effectiveness between multimodal and single mode treatment.
One explanation is that the combined content of the multimodal regimen may be needed for success in many cases because the combination of drinking and driving represents such a complex set of problems and deficiencies.Alternatively, the inclu sion of several approaches could increase the likelihood that at least one approach will have an effect on a larger number of offenders (WellsParker et al. in pressa).The latter option is in keeping with the hypothesis that different people require different treatment strategies for successful outcomes-a compelling possibility with DUI offenders, given the diversity of problems that have been documented in this population (WellsParker et al. 1990).
Followup, which is one multimodal treatment element used with DUI offend ers, also has been evaluated in other man dated treatment populations.Although few welldesigned evaluations of treatment for other mandatory referral groups have been conducted, one study of an EAP found that the addition of routine followup care to an inpatient EAP was marginally effective in improving outcome measures related to alcohol abuse (Foote and Erfurt 1991).Another study examined the comparative effectiveness of employermandated treat ments for predominantly heavydrinking male workers, a majority of whom had been arrested previously for DUI and reported abuse of other substances.The study determined that a multimodal inpa tient treatment with intensive followup that included AA attendance as a component was more effective for reducing subse quent alcohol and other drug abuse than was either AA attendance alone or giving workers a choice between AA and inpa tient treatment (Walsh et al. 1991).

TREATMENT MATCHING
It is evident that particular types of treat ment may be best suited to DUI offenders with certain characteristics-that is, offenders may be matched to optimally effective treatment strategies.According to the matching hypothesis, different types of offenders would require different kinds of intervention for successful out comes (for a more detailed discussion, see the article by Mattson,.The following examples relate findings from single studies that have examined the effects of demographic differences on types of treatment.

Treatment in Relation to Ethnicity, Education, and Age
Subgroups of the DUI offender population have been shown to respond better to some types of treatment, supporting the potential efficacy of matching (reviewed in Wells Parker et al. 1990).A California study (Reis 1982) found that programs involving home study (in which offenders were given reading materials to study on their own) were associated with lower DUI recidivism for Caucasian but not for minority offend ers.A biweekly regimen of unstructured counseling was associated with lower DUI recidivism for offenders with a high school education or less but not for offenders with some college education.
Age also affects the outcomes of some forms of treatment for DUI offenders.Participants in one study received either monthly contact probation sessions for a year, a shortterm educational or thera peutic intervention, or no remediation.The age and education of the offender were found to influence the effectiveness of probation.For offenders over age 55 who had at least 12 years of education, contact probation reduced recidivism by at least 30 percent.However, for older offenders with less education and for offenders between 30 and 55 years old, probation did not reduce recidivism (WellsParker et al. 1990).
For DUI offenders under 30 years of age, treatment effectiveness varied across subgroups of these younger offenders.Contact probation reduced recidivism by at least 30 percent for young minority populations, predominantly African American, who had at least 12 years of education.For young minority offenders with less education, the combination of shortterm intervention and probation was most effective, reducing recidivism by about 25 percent.In contrast, contact probation did not reduce recidivism for the offenders' Caucasian counterpartsthe only subgroup among the younger offenders who showed no benefit from any intervention.WellsParker and col leagues (1990) suggested that "interven tions that provide resources, such as education or interaction with supportive role models (e.g., probation counselors), could be especially effective in countering negative social factors, such as poverty, discrimination, or the negative labeling of minority offenders as 'criminals,' that may exist in some societies and exacer bate future traffic risk" (pp. 281-282).

Treatment in Relation to Gender
WellsParker and colleagues (1990) also found that women arrested for DUI who had severe drinking problems, including those with high blood alcohol concentra tions (greater than 0.2 percent), repeated their offenses more frequently when re quired to complete a questionnaire that assessed their current life status.Among these women, receiving the questionnaire was associated with a 60percent greater frequency of recidivism than among those who did not receive the questionnaire.An independent study replicated this finding (reviewed in WellsParker et al. in pressb).
In interpreting the finding, Wells Parker and colleagues (in pressb) noted that the questionnaire focused on the women's roles in such areas as marriage and family.Most of the women arrested for DUI, however, were separated or divorced.WellsParker and colleagues also considered other studies that demon strated that women with alcohol problems may have a range of emotional and psy chiatric disorders as well.Often these women drink to escape life's problems.It is possible that for women with these problems and who lack common sources of social support, the forced examination of their current life circumstances could have caused a sense of helplessness and hopelessness that may have led to more drinking and impaired driving in an at tempt to escape such problems (Wells Parker et al. 1990).
Although only a few studies (such as those reviewed here) have examined how different demographic groups respond to intervention, those studies suggested that DUI rehabilitation strategies, many of which have been developed for the young or middleage Caucasian male DUI of fender, will not have the same effect on women and different ethnic groups.Fail ure to understand the treatment needs of these groups, which are likely to be seen in increasing numbers in courtreferred populations as the demographic profile and social customs of the United States change, could limit the effectiveness of intervention.

Incentives to Attend Treatment
Not all people who are mandated to attend treatment actually attend.The strength of the mandate to receive treatment is not equivalent for all DUI offenders, because wide variation exists in the United States in the frequency and swiftness of imposing contingent sanctions (e.g., jail time) on those who fail to attend and complete treatment.Offenders' appraisals of the likelihood that a sanction will be imposed, or its severity if it is imposed, are critical in determining whether these people re ceive treatment.For example, if penalties for driving without a license are weak, and there is little chance of being detected when driving without a license, then con tingent reinstatement of the driver's license upon completion of a treatment program may be an ineffective inducement for the offender to enter or complete the program.Thus, DUI offenders' entry and completion rates with respect to mandated treatment may be related to how the offenders per ceive the courts' willingness to impose sanctions for failure to comply with the treatment mandates.

Similarities With Nonmandated Treatment Populations
Although differences between institution ally mandated populations and populations with less obvious sources of coercion often are emphasized, similarities and overlaps also should be considered.For example, a recent trend is to provide alcoholism interventions for alcoholpositive patients in trauma care facilities.Many of these patients have been injured in automobile crashes and have histories of DUI of fenses (Stoduto et al. 1993).Thus, the criminal justice system and the trauma care system represent different points entry into treatment.Whereas not all alcoholaffected drivers injured in crashes are charged with the DUI offense, the behaviors of the undetected drinking drivers might be similar to those of de tected DUI offenders entering the crimi nal justice system.Effective treatments used for DUI offenders in mandated programs might provide useful models for as yet undetected drinking drivers identi fied by other mechanisms as needing treatment for alcohol problems.

IMPROVING TREATMENT FOR DUI OFFENDERS
Available research suggests that mandated treatment for drinking drivers tends to have a small but positive effect on reduc ing subsequent drinking and driving and alcoholrelated crashes.However, licens ing sanctions that reduce offenders' expo sure to all traffic hazards should be combined with DUI offender rehabilita tion programs to enhance general traffic safety.Also, treatment program effective ness in reducing alcohol problems could be improved by expanding the types of interventions offered to DUI offenders, matching offenders to optimal treatments, or identifying costefficient multimodal interventions that could benefit a wide range of DUI offenders.
Increasingly, mandated programs emphasize combination strategiessanctions such as license actions, com munity service, or fines combined with therapy, education, and more monitoringas alternatives to incarceration of DUI offenders (Simon 1992).Such combined strategies are a promising alternative to expensive incarceration in already crowd ed jails.■